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AANS Neurosurgeon : Features

Volume 23, Number 3, 2014

Sport-related mTBI: A Public Health Ethical Imperative to Act

Ross E. G. Upshur, MD; and Paul S. Echlin, MD

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Concussion suffered in sport or recreational activities by children and adolescents is classified by the World Health Organization as a minor traumatic brain injury (mTBI). Cited in a U.S. Center for Disease Control and Prevention (CDC) report to the Congress, these serious traumatic brain injuries suffered in youth sport and recreational activities are referred to as a “silent epidemic.” The report also stated that mTBI is a public health problem, the magnitude and impact of which are underestimated by current surveillance systems (1). The yearly incidence of sports- and recreation-related mTBIs in the United States is estimated between 1.6 and 3.8 million, many of which remain undiagnosed or do not result in doctor or hospital visits. (2)

Today, 11 years after mTBI was characterized as an important public health problem, there exists a large gap of direct, objective, coordinated and comprehensive evidence upon which to measure preventative interventions concerning acute and recurrent mTBI among the youth. (3) This important deficit raises serious ethical issues concerning how best to mitigate the harm of often preventable brain injuries to the vulnerable youth population suffered while in pursuit of the otherwise positive benefits derived from sporting and recreational activities. The effect of concussion on developing brains is of particular concern.

Is mTBI a Public Health Issue?
A public health issue is one that has broad significance to a population requiring the utilization of collective resources to address significant health threats. Essential public health functions relate to targeting and protecting entire populations from disease, preventing injury and illness and promoting health. Public health is informed by epidemiology and rests upon a foundation of securing community health. Health care focuses on treating individuals who are not well, usually after illness or injury has occurred.

Public health works upstream looking for ways to prevent people from becoming sick or injured. Public health problems are often identified by the magnitude of potential harm associated with the health threat. Risks that are prevalent in society with identifiable and well-documented adverse consequences are often targets of public health action. Excellent examples of these are found in controlling tobacco to reduce cancer and cardiovascular disease and seat belt legislation and motor vehicle safety improvements to reduce the risk of death and injury from motor vehicle accidents. The question is whether the magnitude of harm from contact sports in children and youth in terms of mTBI qualifies as a public health problem.

Exposure, Incidence and Health Consequences of mTBI
Children participate in sport (soccer, basketball, rugby, American football and ice-hockey) from the ages of 6 through 16, their formative physical and social development periods. In the U.S., approximately 44 million boys and girls participate in an organized sport annually. (4) Some 7.7 million U.S. high school students participated in school sponsored athletics during the 2012-2013 school year. (5) There has been a 100-percent increase among 8- to 13-year-olds and a 200-percent increase among 14- to 19-year-olds in sports-related emergency room visits for concussion. Concussions represent from 5.5 percent to 22 percent of all high school athletic injuries. (7, 8) There continues to be cultural resistance to the non-biased documentation of the incidence of this injury.

In Australia, an increase of sport-related concussion, along with high levels of public concern, make prevention of head injury in sport a population health priority. (9)

The literature concerning sport-related mTBI has abandoned grading of mTBI by international consensus in 2009, recognizing all brain trauma as serious. (11) The 2012 consensus guidelines state that an individual who is suspected of sustaining a concussion should be removed from that activity and not return until a medical evaluation has been completed. The guidelines state that an individual who suffers a concussion should not return to play until a six-step protocol is completed, with a minimum of 24 hours between each step. These consensus guidelines also make a differentiation between adults and children concerning concussion diagnosis and treatment. (12)

Incidence reporting lacks a direct independent and unbiased standardized approach. Current research is dependent upon prospective evaluation or retrospective review of various hospital emergency department and other injury surveillance data bases that tend to significantly underreport the concussion incidence. (13, 14, 15, 16)

Two recent longitudinal prospective, ice-hockey studies study young adult subject groups (2009-10 junior men and 2011-12 university men and women players) utilizing direct observation, diagnosis and treatment by non-biased specialist physicians that utilized internationally recognized definitions and treatment protocol. These studies demonstrated the significantly underreported incidence of mTBI compared to age, sex and skill level published evidence. (17, 18) The incidence rate (per 1,000 athlete exposures) in these two studies was between three to seven times higher than ever previously reported for the sex, age group and level of sport. In each study, greater than 20 percent of individuals participating suffered a medically diagnosed mTBI during the period of the study. (17, 18)

Halton Student Concussion Education Program examples of interactive modules. Included in these examples are multiple-choice questions concerning presented scenarios that can be discussed by the teacher and students. Also included is an example of the direct module access of mTBI-related videos that enhance and consolidate learning.

There has been no published prospective evidence concerning the objective advanced MRI imaging of sport concussion in the pediatric age group. Recently published advanced MRI evidence from the prospective 2011-12 collegiate ice-hockey study demonstrated acute and cumulative micro structural vascular and white matter injury. (10,19, 20) This important initial evidence, although not directly related due to lack of pathological correlation, converges with the documented evidence of mild cognitive impairment (MCI) and pathological evidence of chronic traumatic encephalopathy (CTE), as well as other neurodegenerative diseases already documented, among individuals that have sustained repetitive brain trauma. (21-25)

Further, and more importantly, the human and economic toll that this injury has upon our culture is also reflected on the less-documented incidence of mental illness (26, 27), associated physical illnesses, as well as loss of academic and occupational productivity among those individuals that sustain this “invisible injury.” (1) A recent Canadian study showed elevated risks of psychological distress, suicidality, utilization of prescription medication for depression and anxiety and other negative social and mental health outcomes associated with mTBI. (28)

A 2013 University of Virginia study documented the results of instrumented American football helmets of participants between 9 and 12 years. A total of 50 players (age = 11.0 ± 1.1 years) on three teams were equipped with helmet-mounted accelerometer arrays, which monitored each impact players sustained during practices and games. During the season, 11,978 impacts were recorded for this age group. Players averaged 240 ± 147 impacts for the season. Some of the impacts measured were some recorded high-magnitude impacts similar to those seen at the high school and college level. (29)

The question that is most obvious concerning these findings is: Knowing that players average 240 impacts per season, why would a parent knowingly allow this? The risk of injury is different than allowing a child to participate in an activity in which he/she may sustain a single, accidental, identified and medically diagnosed/treated head trauma (e.g. waterskiing, basketball and baseball).

Ethical Issues
It is clear that the burden of morbidity and the sequelae from mTBI in children and youth is substantial. This is an ethical issue.

Ethical concerns can arise at both the individual level (as in most medical ethics) or at the collective level in terms of public health ethics. At both levels, minimizing harm and protecting vulnerable persons are central tenets. Vulnerability occurs when persons or populations are unable to optimally protect themselves from hazards or advocate for their own best interests, thus requiring enhanced protections. Typically, we consider children and youth to be vulnerable and this is reflected in many social, cultural and legal practices that seek to protect them from adverse circumstance and risk.

The current data demonstrates that there is converging documented evidence concerning repetitive brain injury suffered in youth sport and recreational activities. Given the status of children and youth as vulnerable populations, the onus for protection from this harm does not accede to the children and youth themselves, but rather to the adults who organize, co-ordinate and fund their sporting activities. They are the stewards of the well-being of children and youth and with them the responsibility for protection lies.

However, we have abundant reason to believe we have failed in our collective responsibility to secure the well-being of youth and children and assure that they grow and develop to their fullest capability. These injuries are preventable.

Moving Forward
If we see mTBI as an educational issue, then solutions will focus on better training for coaches and trainers to identify mTBI more accurately, better awareness among players concerning symptoms, appropriate steps to take in the case of an injury and improved training for educational institutions to accommodate injured athletes. If we see mTBI as a research issue, we will devote resources to better understanding mechanisms of injury, look for cellular markers of damage, look for improved diagnostics and imaging and longer and larger cohort studies to better understand the evolution and consequences of mTBI. All of these proposed remedies are laudable and have significant support. They will take time and investment in resources to come into effect.

However, if we see mTBI as a public health issue, we may wish to ask whether we have sufficient grounds to take precautionary steps to dramatically prevent further injury. We have knowledge of the nature of the injuries and their consequences and the means to protect children and youth from incurring these injuries.

What are the logical and available solutions to changing the sporting environment so that our children develop their social and physical skills through participation in athletics? Dramatic rule changes should be made to the games that children play from the recreational to the elite competitive level. Game and rule structure must be changed to eliminate all purposeful and intentional head contact, and also minimize incidental head contact in all children’s sports. Pat Lafontaine, whose own professional ice hockey career ended prematurely secondary to repetitive brain trauma, succinctly stated (2008 National Academy of Neuropsychologists Sport Concussion Symposium in New York), “The head and neck should be off limits.”

Options include changes that would decrease the number of violent collisions secondary to natural laws; including increasing the size of the playing surfaces and decreasing the number of participants on the field of play. We should also consider eliminating the use of the head in games like soccer (30), and enforcing significant suspensions to participants or supervising adults involved in games in which head injuries occur.

Ultimately, if non-biased surveillance determines that these significant considered changes do not alter the incidence of these serious, and previously non-documented brain injuries, consideration must be given to completely abolishing collision sports for participants under the age of 16. The age of 16 is considered as the earliest age at which an individual has the minimal ability of consent and capacity to make an educated decision concerning taking responsibility for their own independent actions.

Recently, the Ministry of Education in Ontario, Canada, mandated publicly funded schools to institute concussion curriculum education for all students grade one to 12, as well as a return-to-learn and return-to-play protocol for all students by Jan. 31, 2015. Addressing the education of the next generation is a significant step in the self-advocacy, and generational change concerning this injury and the sports that are causal. (31) The Halton District School Board (HDSB, Ontario, Canada) has mandated curriculum-based concussion education (HSCEP) for all grade nine students based on core interactive modules, as well as an adopted set of Ontario Physical Health and Education Association (OPHEA) guidelines for return-to-learn and return-to-play guidelines for September 2014. (32)

Certain evidence of causality is not needed to invoke protective measures. This was noted by two major Canadian commissions of inquiry, including one on severe acute respiratory syndrome (SARS). (33, 34) It is worth noting that the accumulated evidence regarding mTBI in youth and children is approaching a more mature level than that of the Canadian blood system or in the case of SARS.

So, we know more about mTBI, but not everything. The point of the precautionary approach is to forego more specific evidence in order to mitigate harm. If we have the means to do that, we have the moral obligation to act upon this knowledge.

If mTBI is truly both a public health problem and an important ethical concern, we would do well to reflect on this and take appropriate and immediate action to protect the futures of hundreds of thousands of youths involved in contact sports. There is an imperative to act concerning structural changes in games that our children play, along with early mandated publicly funded school mTBI education for our next generation of athletes, parents, coaches, educators and administrators.

Our children should have the right to play at all levels of skill in an environment without fear of brain injury from intentional “win-at-all-costs” violence, or unrecognized repetitive trauma.

Ross E. G. Upshur, MD, is the scientific director, Bridgepoint Collaboratory for Research and Innovation, and head of the division of clinical public health at the University of Toronto Dalla Lana School of Public Health. Dr. Upshur also is the Canada Research Chair in Primary Care Research. At the University of Toronto, he is a professor at the department of family and community medicine and Dalla Lana School of Public Health. Paul S. Echlin, MD, is a primary care sports medicine specialist, currently practicing at the Elliott Sports Medicine Clinic, Burlington, Ontario. Board certified in family medicine (CCFP), and fellowship-trained in sports medicine in Canada and United States, Dr. Echlin was junior hockey team physician for 10 years in Canada and the United States. Currently primary investigator of the Hockey Concussion Education Project, Dr. Echlin also served as chair of the Sport Neurotrauma and Concussion Initiative (SNCI) Research Committee. The authors reported no conflicts for disclosure.

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